Self Referral Form

Use this service to submit your interest in receiving counselling and support from YPI Counselling. This service is primarily available to children and adults within the Basingstoke and Deane area.

Submission takes around 10 minutes.


If you need urgent help or support in a crisis

YPI is not able to offer crisis/urgent support. If you need more immediate support please consider the following:

  • Request an urgent appointment with your GP
  • Attend your local A&E department
  • (Under 18's) Contact Child Line on 0800 111
  • (Over 18's) Contact the Samaritans on 116 123

Please note we cannot work with people under an Adoption or Special Guardianship Order. Please contact Barnardo's for further information and support.

Before you start

You can also register by printing off our referral form.

You cannot register for this service if you live outside of the UK.



Self Referral Form


Information about you


Date of Birth


Contact information

Please provide a phone number and email address that you consent to YPI using to make and confirm appointments with you.

Emergency contact information

Please provide a phone number for use in an emergency.

Work/Education Status


Do you have a physical, learning or mental health condition that has been diagnosed?

Please only provide this information if you have been diagnosed by a Health Professional.
Please state what your diagnosis has been, past or present and whether you are currently on medication.

Which sexual orientation do you identify as?


Are you a parent and under 18?


Are you a young carer?

Please state who you care for and why.

Do you suffer from poverty issues?

Please give more information.

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Please give more information.

Have you ever had involvement with the Courts?

Please give more information.

What are the main reasons you would like to have counselling support?


Issues you would like support with:

Please select a minimum of three. The more information you provide the better we can support you.

Have you received support in the past?

Please state who with and when.

How did you hear about YPI?


Are you contacting YPI yourself?

If you are a parent or guardian completing this form on the behalf of a young person, please select yes.

Referring Agency Information

If you are referring this individual on their behalf and are not their parent or guardian, please provide information about your agency or organisation below.

Please acknowledge the following statement:

Any child 14 years and under must be accompanied by an appropriate adult to and from appointments.

Please acknowledge the following statement:

YPI staff shall ensure that the young person safely leaves the Orchard building however parents acknowledge that it is their responsibility to ensure the safety and well-being of the young person once they have left the premises and must arrange a safe travel route home with them.
By completing this form, you are giving consent to YPI to use your data for the purposes outlined in our Data Protection Statement. More information.

Contact Us